Trump didn’t gut foreign aid last time. This time could be different.

On the campaign trail, President-elect Donald Trump and Vice President-elect JD Vance did not sound like guys likely to support foreign aid spending.

Vance would rail against Kamala Harris, who he alleged “taxed money from the American taxpayer, sent it off to China and to foreign regimes all over the world.” (It’s not clear what exactly he meant by this.) Trump blasted US aid to Ukraine, joking that Ukrainian president Volodymyr Zelenskyy is “maybe the greatest salesman of any politician that’s ever lived. Every time he comes to our country, he walks away with $60 billion.”

Sure enough, this skepticism applies to more traditional foreign aid spending as well, through vehicles like the US Agency for International Development (USAID). All four budget proposals during Trump’s first term included major cuts to foreign aid; the last one proposed a 34 percent cut to global health programs, including an over 50 percent cut to the Global Fund, the main international body coordinating donor funds to fight malaria, tuberculosis, and AIDS.

Project 2025, the notorious Heritage Foundation project outlining policy for a second Trump term, commissioned Max Primorac, who served in USAID during Trump’s first term, to outline a plan for aid. His focus was on fighting DEI and reproductive health initiatives, combating Chinese influence, returning support to fossil fuels in developing countries, and enacting “deep cuts” to the aid budget.

All of that reads like a case that foreign aid advocates should be freaking out right now, the same way abortion rights and immigrant advocates are. But the truth is more nuanced.

The president does not control the foreign aid budget directly, and during Trump’s first term, a bipartisan coalition in Congress ensured that none of the cuts were adopted. While his budgets proposed cuts to institutions like the Global Fund, the US also made large pledges of increased support during his term, albeit largely at Congress’s instigation. Mark Green, the former Congress member who Trump tapped to head USAID last time, is widely respected in the aid world and pursued reform policies that honestly don’t look very different from those of Biden’s administrator, Samantha Power, or Obama’s Raj Shah and Gayle Smith.

Experts and advocates I spoke with emphasized that no one really knows what Trump II will bring, or how similar/different it will be from his first term. Some of his Cabinet picks, like Florida Sen. Marco Rubio or North Dakota Gov. Doug Burgum, seem like people any Republican could’ve chosen. Others, like Robert F. Kennedy Jr. or Matt Gaetz, seem wildly unqualified and bizarre. But while little is certain, aid experts emphasized that we should not assume big cuts or other major damage to the US foreign aid system.

“I have every expectation that we will see an attempt to cut funds for these areas, and those proposed cuts are profoundly dangerous,” Colin Puzo Smith, director of global policy at the antipoverty group RESULTS, told me. “But it’s so, so, so important for the global health advocacy community to remember, for the public to remember, and for other country leaders to remember, that those decisions don’t sit with the White House. They fall to Congress.”

The best case that foreign aid will survive the Trump years without major damage is the record of Trump I.

If you look at total foreign assistance spending for fiscal years 2018 and 2019 (the two years after Trump took over but before Covid-19), foreign aid funding was basically the same in dollar terms, only declining slightly due to inflation. When you account for military aid declining as the fight against ISIS in countries like Iraq and Jordan wound down, the picture looks even better.

The basic reason that funding remained high despite budget requests from Trump proposing deep cuts is that members of Congress, in particular Republicans who were chairing relevant subcommittees in the Senate and House for Trump’s first two years, were adamant that funding stay high. They were not shy about denouncing his proposed cuts, even very early in his term.

The most important institutions on aid funding in Congress are the State and Foreign Operations subcommittees of the appropriations committees for each chamber. Appropriations is in charge of all funding that has to be regularly authorized; that excludes things like Social Security or Medicare but includes the entire foreign aid budget.

The Republicans chairing the subcommittees during Trump’s first term were furious at the prospect of foreign aid reductions. “The proposed cuts to U.S. diplomacy and assistance are sweeping and potentially counterproductive to our national security goals,” Hal Rogers, the Kentucky Republican in charge of the House subcommittee, said in a 2017 statement.

The Senate chair was Lindsey Graham, a former Trump critic who had by this point become a major booster. All the same, Graham pronounced the foreign aid cuts “dead on arrival,” and argued Trump’s cuts to the State Department could lead to “a lot of Benghazis.”

The health research group KFF has a useful tool allowing you to compare global health funding each year in the President’s budget, both in House- and Senate-proposed spending bills and in actuality. In almost every case, you see Congress pushing for more spending than Trump did, and winning.

Trump wanted to provide $1.125 billion to the Global Fund, the anti-malaria/TB/HIV group. The final bill provided $225 million more than that. Trump wanted $424 million for USAID efforts against malaria. The House upped that to $505 million, the Senate to $655 million, and the final passed version was $755 million, plus another $202 million for the National Institutes of Health to research malaria.

That reflects a deep bipartisan commitment to global health funding, one that persists to this day. Graham is currently the ranking member on the funding subcommittee, and likely will be chair again come January. Florida Rep. Mario Diaz-Balart, who has succeeded Rogers as chair of the House subcommittee, is also known as an enthusiastic supporter of global health funding.

In late 2022, under President Joe Biden, a bipartisan deal was cut involving these players enacting major increases in a number of global health funding streams. Those same actors could do that again.

“There remain a lot of people in key positions in Congress who are very supportive of global health,” Chris Collins, head of Friends of the Global Fight, which pushes for increased global health support from Congress, told me. “Global health has always been bipartisan.”

The foreign aid team that Trump put in place last time also gets high marks from observers in the field. His USAID pick Mark Green sought to reorient the agency toward emphasizing evidence-based interventions and programs run by locally rooted organizations, as opposed to US-based contractors. His program in that vein, the New Partnership Initiative, was quite similar to the Local Solutions program under Obama and the pledge by Power to increase the share of aid running through local groups to 25 percent.

“Thanks to the able leadership of Administrator Mark Green, USAID has avoided much of the harm many feared could befall it under an administration that has so often positioned itself at odds with a development agenda,” the Center for Global Development’s Sarah Rose and Erin Collinson wrote when he stepped down in 2020. “When Green steps down from the job today, he will leave behind an agency that has largely continued to champion development.”

The basic bull case for Trump II is that his second USAID administrator will be a broadly liked technocrat like Green, focused on improving efficiency rather than pursuing a partisan agenda focused on gender or reproductive health issues. That, plus a Congress willing to fund aid programs generously, could result in basically decent outcomes, if not spectacular ones.

The first Trump term was not an unqualified success from a foreign aid standpoint. While his cuts did not make it through Congress, the fact that he proposed them put aid agencies under pressure and added uncertainty that they’d be able to continue programs.

He also engaged in some classic Republican policies that global health experts disdain, like reviving the Mexico City Policy, a Reagan-era measure that bars aid to organizations that provide abortions. This is an example of Trump being a standard Republican president — every Republican since Reagan has adopted that policy, and every Democrat in office has then rescinded it. It’s more or less an American tradition at this point. But the policy is also associated with worse maternal health outcomes in recipient countries. Meanwhile, other Trump appointees pushed for abstinence-only sex education programs to combat HIV and other sexually transmitted diseases, an approach that most research suggests is ineffective.

More to the point, Trump II is by no means guaranteed to be like Trump I. His appointments so far have indicated he’s willing to depart from normal US policy more drastically; compare, for instance, his first-term choice of respected former Sen. Dan Coats to be director of national intelligence to his choice this time of Tulsi Gabbard, who is incredibly close to the Russian government.

When it comes to global health, two big changes stand out. One is that Trump II will be a post-Covid administration, and thus will reflect the deep skepticism of multilateral health institutions that has developed on the right as a result of the pandemic. A few months into the pandemic, Trump announced he was withdrawing the US from the World Health Organization (WHO), citing its failure to contain the virus and arguing it was excessively close to the Chinese government.

While the Biden administration reversed course on that decision, GOP anger toward the WHO in particular has lingered. The most recent Republican appropriations bill in the House zeroed out funding for that agency as well as the UN Population Fund, UNESCO, and the UN Environment Fund, among others.

Diaz-Balart, the chair of the House Appropriations Subcommittee on State and Foreign Operations, crafted that bill and is known as a moderate who resisted deeper cuts in Trump’s first term. If he wants to zero out WHO funding, it’s a fair bet it’ll be zeroed out.

“The multilateral space is one where you’re going to see a shift,” Elizabeth Hoffman, executive director for North America at the ONE Campaign and a veteran foreign aid staffer in Republican congressional offices, told me. “There’s going to be a shift from trying to do things through multilateral mechanisms and looking at a more bilateral framework.”

It’s not clear that this skepticism will extend to multilateral funding mechanisms like the Global Fund or Gavi. But there’s another factor in Trump II of potential concern for Gavi, especially: Robert F. Kennedy Jr.

Since Kennedy dropped out of the presidential race and endorsed Trump, the latter has repeatedly suggested that RFK will have a role as a kind of public health czar. He made it official by naming Kennedy as his pick to run the Department of Health and Human Services.

Kennedy is perhaps the most influential anti-vaccine activist not only in the US, but the world. A few months after he visited the nation of Samoa in 2019 and campaigned with anti-vaccine advocates there, a massive measles outbreak, driven by declining vaccination rates, broke out, killing some 83 people, mostly children, in a country of 217,000. The US population equivalent would be over 136,000 deaths.

It’s not clear how much power Kennedy will have to repeat his Samoa performance in the US. He told NPR the morning after the election, “We’re not going to take vaccines away from anybody.” But he used the same appearance to emphasize that he thinks “the science on vaccine safety particularly has huge deficits,” suggesting he maintains his belief that they’re unsafe.

How much power Kennedy will have to reduce vaccinations in the US is unclear, and how much power or interest he’ll have in reducing them abroad is even less clear. But whereas the last Trump administration declined to propose funding cuts for the vaccine funding group Gavi, even as it sought to cut almost every other kind of foreign aid, it’s not hard to imagine Kennedy’s presence pushing them to include Gavi and other vaccination programs in their budget slashing agenda.

Such cuts, if enacted, would be tragic. Economic research suggests that Gavi’s support for national vaccination programs can save a life for a few thousand dollars, or even less. It’s one of the most cost-effective things the US government does, in any domain. If anti-vaxxers in Trump’s orbit target it, and if Congress goes along with them, the ramifications would be devastating.

Perhaps the most disturbing omen for Trump’s foreign aid policy is the report from the Washington Post that he wants to revive “impoundment,” a practice Congress banned after Watergate in which the president simply refuses to spend money that’s been allocated by Congress. Trump publicly flirted with using a related tool, called rescission, to unilaterally cut foreign aid in 2019. This time he seems more serious.

If Trump fully usurps the power of the purse from Congress, then any hope for foreign aid premised on the bipartisan congressional coalition behind foreign aid spending becomes hollow. Trump could simply overrule the Lindsey Grahams and Mario Diaz-Balarts of the world. Then we’d be in an incredibly dark reality indeed.